Mildred Iola ThomasAPPLICATION AND PERMIT FOR DISPOSITION OF HUMAN REMAINS
USE BLACK INK ONLY -MAKE NO ERASURES, WHITEOUTS OR OTHER ALTERATIONS
1A. NAME OF DECEDENT -FIRST (GIVEN) 1B. MIDDLE
1C. LAST (FAMILY)
1118. DATE BURIED
2. DATE OF BIRTH
3. DATE OF DEATH
1 4. SEX
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MONTH,, DAY, T4YEAR
MONTH DAY. YEAR
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12A. NAME AND ADDRESS OF CALIFORNIA CREMATORY
DATE CREMATED
x7/ 31/19_w
9
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5A. CITY OF DEATH
158. COUNTY OF DEATH --OUTSIDE CALIF.,
6. NAME, RELATIONSHIP, FULL MAILING ADDRESS AND ZIP CODE
asa.S2z�.:v� a,.ca. *�_City
I ENTER STATE
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OF INFORMANT
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7A. TYPED NAME AND ADDRESS OF CALIFORNIA -FUNERAL DIRECTOR OR
PERSON ACTING AS SUCH M. CALIF. LICENSE NUMBER
[xi.
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2952 1
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-IF APPLICABLE
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8A SIGNATURE OF APPLICANT -Person taking permit' 8B. DATE IGNEE
hereby acknowledge as applicant that the proposed disposition stated herein is one of the dispositions authorized by
ACKNOWLEDGMENT OF APPLICANT
PERMIT SONS
PERMIT IS ISSUED IN ACCORDANCE WITH PROVI- 9A. AMOUNT OF;,FEE PAID' 9B. DATE PERMIT ISSUED' 9C. SIGNATURE OF LOCAL
SIONS OF THE CALIFORNIA HEALTH AND SAFETY CODE I I
AND IS THE AUTHORITY FOR THE DISPOSITION SPECIFIED I L. �.
AUTHORIZATION OF IN THIS PERMIT. zT a t (� f� 1 `
LOCAL REGISTRAR NOTE: THS GIVES NO RIGHT OF DISPOSAL WTSME OF CALIFORNIA. 0 L - F / �
ANY CHANGE IN DISPOSI 9D. ADDRESS OF REGISTRAR OF DISTRICT OF DEATH- I �4E. ADDRESS OF REGISTRAR OF .DISTRICT OF DISPOSITION -
TION REQUIRES A NEW IF DEATH OCCURRED IN CALIFORNIA I � IF DISPOSITION IS TO OCCUR IN ANOTHER DISTRICT IN CALIFORNIA
PERMIT TO SHOW FINAL S'a�'�::e �..a our t `� health It Department ax ,.'�" t +�'n t I
DISPOSITION. ;-� , a .., I �.
.650 iaSl d�T tile;v, ked , € g0 � 01i
ISSUING PERMIT
10. AUTHORIZED DISPOSITION(S) CHECK APPLICABLE. ITEMS - FORCORONER'S USE ONLY
❑ A. BURIAL (INCLUDES ENTOMBMENT) E TEMPORARl ENVAULTMENT I. DISPOSITION PENDING -REMAINS LOCATED AT
B. CREMATION - (Name and Address)
I _ _ Fi DISINTER
' ❑C. DISPOSITION OF CREMATED REMAINS OTHER 4
G. SHIP IN TO CALIFORNIA
THAN IN A CEMETERY
D. SCIENTIFIC USE H. TRANSIT Td -OUTSIDE OF CALIFORNIA .m
COPY 2 IS RETAINED BY THE PERSON IN CHARGE OF THE CEMETERY,=`CREMATORY, FACILITY FOR SCIENTIFIC USE, OR BY THE PERSON IN
CHARGE OF DISPOSING OF THE CREMATED REMAINS.
COPY 2 STATE OF CALIFORNIA, DEPARTMENT OF HEALTH SERVICES, OFFICE OF STATE REGISTRAR VS9 (REV.6/91)
11A. NAME AND ADDRESS OF CALIFORNIA CEMETERY
i
1118. DATE BURIED
111C. SIGNATURE OF PERSON IN CHARGE OF BURIAL
BURIAL
12A. NAME AND ADDRESS OF CALIFORNIA CREMATORY
DATE CREMATED
IG TUBE OF PERSON IN CHARGE OF CREMATION
CREMATION
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1128.
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112C
1 a
Redding, CA
13A. NAME AND ADDRESS OF CALIFORNIA FACILITY RECEIVING REMAINS
13B. DATE RECEIVED
13C. SIGNATURE OF PERSON IN CHARGE OF FACILITY
SCIENTIFIC
1
USE
I
I
I
1
-
I
14A. NAME AND ADDRESS IN RECEIVING STATE OR COUNTRY WHERE
14B. DATE SHIPPED
14C. ADDRESS AND SIGNATURE OF PERSON IN CHARGE
REMAINS OR CREMATED REMAINS ARE TO BE SHIPPED
I
I OF PLACING WITH THE CARRIER
TRANSIT
Blair ea +eter- P � c-.1aa ,
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SCATTERING AT SEA
15A. ADDRESS, NEAREST POINT ON SHORELINE, OR OTHER DESCRIPTION'SUF-
15B. DATE OF
15C. SIGNATURE OF PERSON IN 15D. LICENSE NUMBER
OR
FICIENT TO IDENTIFY FINAL PLACE AND CA DISTRICT OF DISPOSITION
I DISPOSITION
I CHARGE OF DISPOSITION I OF CREMATED RE -
DISPOSITION OTHER
I I MAINS DISPOSER
THAN IN A CEMETERY
I v' -IF APPLICABLE
COPY 2 IS RETAINED BY THE PERSON IN CHARGE OF THE CEMETERY,=`CREMATORY, FACILITY FOR SCIENTIFIC USE, OR BY THE PERSON IN
CHARGE OF DISPOSING OF THE CREMATED REMAINS.
COPY 2 STATE OF CALIFORNIA, DEPARTMENT OF HEALTH SERVICES, OFFICE OF STATE REGISTRAR VS9 (REV.6/91)